Appropriate Pressure Relationships – Inspecting and Maintaining
HOSPITAL NAME AND DEPARTMENT
Title: / Appropriate Pressure Relationships – Inspecting and Maintaining / Number:
Author: / (INSERT NAME OF AUTHOR) / Effective Date:
Owner: / (INSERT NAME OF OWNER) / Revision: / 00
Reference: / The Joint Commission EC Chapter / Standard : / EC.02.05.01 EP15

PURPOSE

The purpose of this work instruction is to provide a standard procedure for the installation and maintenance of the ventilation systems to ensure the appropriate pressure relationships, air exchange rates, and filter efficiencies that serve areas specially designed to control contaminants (e. g., biological agents, gases, fumes) atHospital name.

responsibility

The (INSERT TITLE OF RESPONSIBLE INDVIDUAL(s)) ensures that all specially designed ventilation areas requiring pressure relationships, air exchange rates, and filter efficiencies are maintained per original design criteria and code requirements.

procedure

All operating and procedure suites throughout Hospital locations are tested for particulates and air exchange rates at least annually. All filters associated with ventilation systems are on a scheduled replacement program. All exhaust systems are maintained annually. All isolation and reverse isolation rooms are tested at least annually. These areas are tested daily while in use.

(INSERT TITLE OF RESPONSIBLE INDVIDUAL(s)) maintains construction sites with negative air machines in order to eliminate the transmission of dust into adjoining patient care areas. These areas are checked daily.

All testing, except the construction areas, is scheduled through the job title. All documentation pertaining to these tests is maintained in the (INSERT LOCATION OF TESTING/DOCUMENTATION STORAGE).

Job Title/Department maintains the active construction areas documentation until the project is complete. The associated documentation is then turned over to the Facilities Department.

Biological Safety Cabinets (BSC) and Chemical Fume Hoods (CFH) are tested annually and any filter changed as required. The copies of the certification documentation should be forwarded to Job Title.

Areas evaluated for inclusion in this program are:

  • Operating Rooms
  • Special Procedure Rooms
  • Delivery Rooms for Patients with Communicable Diseases
  • Protective Environment (PE) Rooms
  • Laboratories
  • Pharmacies
  • Central Sterile Clean Room
  • Central Sterile Decon Room
  • Central Sterile Storage Room
  • Bone Marrow Transplant Areas
  • Airborne Infections Procedure or Isolation Rooms (especially where tuberculosis may be expected)

Negative Room Monitoring, Testing and Filter Replacement

Negative Air Machine/BSC/CFH P.M. PROCEDURES

(INSERT DEPARTMENT NAME) staff assigned will adhere to the following procedures:

  1. Notify (INSERT TITLE OF RESPONSIBLE INDVIDUAL(s) INCLUDING APPROPRIATE CLINICAL STAFF) of the appropriate area.
  1. Turn off all power to HEPA filter ventilation unit.
  1. Workers are instructed to wear protective clothing such as: Scrubs, Latex Gloves, Goggles and Approved Respirator.
  1. Change filters - All used filters are to be red bagged and discarded in accordance with Infectious Waste Control Policy.

NEGATIVE AIRBORNE ISOLATIONROOM MONITORING PROCEDURES

(INSERT RESPONSIBLE DEPARTMENTS(s) INCLUDING APPROPRIATE CLINICAL STAFF) assigned will adhere to the following procedures:

  1. Readings shall be taken, and smoke test performed in all negative pressure patient’s room daily, when in use (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. All readings shall be verified by signatures of Nursing and Engineering Staff on the daily sheet attached (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Readings are taken from the Equipment name, if used set in the (-) negative position (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. A reading of -.01, or greater vacuum, and a successful smoke test means the room is available for airborne infectious patient use (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Green indicator light should be visible with door closed (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Use another room, if abnormal readings and green light are not present. If another room is not available call INSERT RESPONSIBLE DEPARTMENTS(s) at (INSERT EXTENSION/PHONE NUMBERS FOR BOTH NORMAL AND OFF HOURS) off-hours for a portable unit to be delivered (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Please do not try to adjust the monitors (INSERT RESPONSIBLE DEPARTMENTS(s)).

POSITIVE AND NEGATIVE ROOM MONITORING PROCEDURES (other than airborne isolation rooms)

INSERT RESPONSIBLE DEPARTMENTS(s) INCLUDING APPROPRIATE CLINICAL STAFF)assigned will adhere to the following procedures:

  1. Readings shall be taken, and smoke test performed in all positive pressure rooms at least annually and daily if an "APPROVED" constant monitoring system is not visible and in working order (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. All readings shall be verified by signatures of Nursing and Engineering Staff on the daily sheet attached (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Readings are taken from the Equipment name, if used set in the (+) positive position (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. A reading of +.01, or greater pressure, and a successful smoke test means the room is available for operative or invasive procedure use (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. Green indicator light should be visible with door closed (INSERT RESPONSIBLE DEPARTMENTS(s)).
  1. If abnormal or negative readings and green light are not present inform peri-operative manager immediately and take the room out of service until repairs are completed and positive pressure documented.
  1. Please do not try to adjust the monitors.

The Following is a List of Negative Pressure Airborne Isolation Ventilation Rooms

Insert List of Rooms Here

The Following is a List of Positive Pressure and Negative Pressure Ventilation Rooms (other than airborne isolation rooms listed above)

Insert List of Rooms Here

  • Associated Documents

Infectious Waste Policy

Daily Sheets

Other Applicable Policies

Document review

Organization Name requires documentation to be reviewed and updated every (INSERT HOSPITAL REVIEW REQUIREMENT TIME FRAME) at a minimum according to policy.